NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST: Clinical Chemistry Guidelines
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1 Adrenocortical Insufficiency Guideline Document Information Policy Reference: Adrenocortical Insufficiency Issue: 1: Version 3 Author Job Title: Peter Prinsloo Consultant in Chemical Pathology STATUS: FINAL First Issued On: June 2000 Latest Reissue Date: March 2008 Document Derivation: See references Ratified By: Department of Clinical Pathology Department of Diabetes and Endocrinology Review Date: March 2010 (or sooner if necessary) Consultation Process: Peer Reviewed Distribution: Clinical Pathology Website Change record Date Author Description Change Record June 2000 Peter Prinsloo Nigel Lawson New Policy Version 1 June 2005 Peter Prinsloo Lorraine Brunt Update with minor word changes Version 2 Nigel Lawson March 2008 Peter Prinsloo Update with minor word changes Version 3 Created on 14/03/2008 Page 1 of 5
2 Adrenocortical Insufficiency Guideline (ADDISON S DISEASE) Common Causes Autoimmune adrenalitis Tuberculous adrenalitis Rare Causes Adrenal haemorrhage and infarction AIDS Bacterial and fungal infections Metastatic malignancy Amyloid/Sarcoid Haemochromatosis Pituitary disease Clinical Features Cortisol Deficiency - Weakness - Anorexia - Fatigue - Postural hypotension - Nausea - Vomiting - Hypoglycaemia - Weight loss - Mineralocorticoid Deficiency - Renal sodium wasting Created on 14/03/2008 Page 2 of 5
3 - Potassium retention - Severe dehydration Hyperpigmentation due to ACTH excess is the classical finding in chronic primary adrenocortical insufficiency. Investigations Some steroids (i.e. hydrocortisone and prednisolone) will cross react with the cortisol assay. Dexamethasone does not cross react and therefore can be used if a patient needs to be maintained on steroid therapy. Initial Tests Plasma (lithium heparin) - Sodium - Potassium - Urea - Creatinine Plasma (fluoride oxalate) - Glucose N.B. A random cortisol is of little use unless the patient is stressed e.g. acutely ill, shocked, hypotensive or hypoglycaemic. In the stressed situation an inappropriately low level of cortisol (<100nmol/L) will usually indicate adrenal insufficiency. Created on 14/03/2008 Page 3 of 5
4 Short Synacthen test Can be performed at any time in acute situations Patient preparation: None required unless the patient is on glucocorticoid steroids. If so change to the equivalent dose of dexamethasone 24 h before commencing test. Protocol Time 0 Collect Basal blood sample (10ml plain clotted) for cortisol Give 250ug of Synacthen (Tetracosactrin, available from pharmacy) either im or iv. Time 30 Collect sample for cortisol (as above) at exactly 30min. Send both samples to the laboratory (in the same bag) Ensure tubes are clearly labelled 0 min and 30 min and put Short Synacthen Test on the form (only 1 form is required) N.B. In some situations (i.e. outpatient or strong suspicion of Addison s disease) a specimen for ACTH should be taken at the same time as the time 0 cortisol. Specimens for ACTH must not be taken after administering Synacthen. The ACTH will only be assayed if the cortisol response is inadequate. ACTH assay: 5ml EDTA plasma Pink top plastic tube Collect specimen on ice and send to Clinical Chemistry immediately Further Investigations Further tests are available to help confirm the presence and cause of adrenal hypofunction Contact either the duty Biochemist or Consultant Endocrinologist at this stage. Created on 14/03/2008 Page 4 of 5
5 References Disorders of the Adrenal Cortex. Bailliere s Clinical Endocrinology and Metabolism 1992; 6(1): Disclaimer: These guidelines have been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of the clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Created on 14/03/2008 Page 5 of 5
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